Title: Incidence of Peripheral Arterial Disease in Diabetic Foot Infection Patients: A Prospective Study

Authors: Dr V.K.Sharma, Dr Puneet Mahajan, Dr Rohit Dadhwal, Dr Anupam Jhobta

 DOI:  https://dx.doi.org/10.18535/jmscr/v5i1.151

Abstract

A prospective study was conducted on 30 patients with Diabetes. Patients were evaluated on the basis of history, clinical examination, laboratory investigations, conventional radiological investigations and Arterial Doppler lower limb and Ankle Brachial Index assessment of the affected foot. The incidence and prevalence of peripheral vascular disease (PAD) increases with age in both diabetic and non-diabetic subjects and, in those with diabetes, increases with duration of diabetes1 Given the inconsistencies of clinical findings in the diagnosis of PAD in diabetic patient, measurement of ankle brachial pressure index (ABPI) has emerged as the relative simple, non-invasive and inexpensive diagnostic tool of choice. An ABPI < 0.9 is not only diagnostic of PAD even in asymptomatic patients, but is also an independent marker of increased morbidity and mortality from cardiovascular disease. In our study all thirty (100%) patients presented with ulcer. Twenty-two (73%) presented with single ulcer while eight (27%) patients presented with multiple ulcers. 86% patients had inadequate blood sugar control. 40% of patients presented with Grade II ulcers (according to Wagner’s Classification) followed by Grade III (37.5%) and Grade I (16%).  Radiological examination of the foot showed changes in 17 (56%) patients. Commonest finding was osteomyelitis 7(23%) patients. 18(60%) patients were found to have peripheral arterial disease diagnosed on the basis of decreased ABPI (ankle brachial pressure index). One patient (3%) had ABPI abnormally high (value >1.4) due to calcification of wall and 11 (36%) had normal ABPI.  Lower values of ABPI were observed with worsening of ulcer grade on Wagner Classification. We conclude that ABPI is very important non invasive adjunct for diagnosis of peripheral artery disease in diabetic patients.

Key words: ABPI- Ankle Brachial Pressure Index : PAD- Peripheral Arterial Disease

References

1.      Dawson DL, Hiatt WR, Creager MA, Hirsch AT (2002) Peripheral arterial disease: medical care and prevention of complications. Preventive Cardiology 5(3): 119

2.      Singh et al, 2005; Vasc Health Risk Manag; 2007 February;3(1):65-76.

3.      American Diabetes Association (ADA; 2003) Peripheral arterial disease in people with diabetes. Diabetes Care 26(12): 3333– 41.

4.      Delbridge L, Ctercteko G, Fowler C, Reeve TS, Le Quesne LP. The etiology of diabetic neuropathic ulceration of the foot. Br J Surg 1985; 72(1):1-6.

5.      Lipsky BA. Infectious problems of diabetic foot in diabetic patients. In, The Diabetic Foot, 6th edition. J.H Bowker, M.A. Pfeifer, eds, St. Louis, Mosby, 2001,pp 467-80.

6.      MacMohan MM, Bistrian BR. Host defenses and susceptibility to infection in patients with diabetes mellitus. Infect Dis Clin North Am 1995;9:1-10

7.      Hankey GJ, Norman PE, Eikelboom JW (2006) Medical treatment of peripheral arterial disease. Journal of American Medical Association 295(5):547-53.

8.      Wilson RM. Neutrophil functions in diabetes. Diabet Med 1986; 6:509-12.  

9.      Thakur R S, Minhas S S, Dhiman D S, Abbey R K. Colour flow Doppler verses Arteriography in Peripheral Vascular Disease. Indian J Surg 2006; 68:1.

10.  Khosla HL, Caroli RK, Bahl AL. Peripheral vascular disease in diabetes mellitus-A clinical study. Ind J Med Sci. 1966; 20 : 698.

11.  Bonham PA. Get the PAD Out: noninvasive assessment for lower extremity arterial disease using ankle brachial index and toe brachial index measurements. JWOCN. 2006; 33:30-41.

12.  Broadstone VL, Cyrus J, Pferter MA, Greene DA. Diabetic peripheral neuropathy. Part 1 sensorimotor neuropathies. The Diabetic Educator 1987; 13: 30-35.

13.  Cyrus J, Broadstone VL, Pferter MA, Greene DA. Diabetic peripheral neuropathyPart II. Autonomic neuropathies. The Diabetic Educator 1987 ; 13 : 111-114.

14.  Boulton AJM, Hardisty CA, Belts RP. Dynamic foot pressure and other studies as diagnostic and management aids in diabetic neuropathy. Diabetes Care 1983; 6: 26-33.

15.  Brand PW. The Sensitive foot (including leprosy). In : Johns MU (ed) Disorders of the foot. WB Saunders Co., Philadelphia 1982; Vol.2.

16.  Boyko EJ, Ahroni JH, Stensel V. Forsberg RC, Davignon DR, Smith DG. A prospective study of risk factors for diabetic foot ulcer. The Seattle Diabetic Foot Study. Diabetes Care 1999; 22 (7): 1036-1042.

17.  Fagerberg SE. Diabetic Neuropathy: a clinical and histological study on the significance of vascular affections. Acta Med Scand 1959; 164(suppl) 1: 97.

18.  Wheat LJ, Allen SD, Hunry M, Keinek MD et al: Diabetic foot infections. Bacteriologic analysis. Arch Intern Med 1986; 146: 1935-1940.

19.  Hiatt WR. Medical Treatment of periph-eral arterial disease and claudication. N Eng J Med. 2001;344:1608–21.

20.  Doobay AV, Anand SS. Sensitivity and specificity of the ankle brachial index to predict future cardiovascular outcomes: systematic review. Arterioscler Thromb Vasc Biol. 2005;25(7):1463–9.

21.  Feigelson HS, Criqui MH, Fronek A, Langer RD, Molgaard CA. Screening for peripheral arterial disease: the sensitivity, specificity, and predictive value of non-invasive tests in a defined population. Am J Epidemiol.1994; 140:526–34.

22.  Polak J F, Karmel M I, Mannick J A. Determination of the Extent of Lower Extremity Peripheral Arterial System With Colour assisted Duplex Sonography; Comparision with Angiography. American Journal Roentgenology 1990; 155:1085-1089.

23.  Mo Al-Qaisi, David M N, David H K, Sam K, Mo Hamady. Imaging of Peripheral Vascular Disease. Medical Imaging 2009;2:25–34.

Corresponding Author

Dr V.K.Sharma

Associate Professor, Deptt.of Surgery

IGMC, Shimla (H.P.) 171001 INDIA

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